FREE CCDS Sepsis Criteria and Documentation (Sepsis-3) Questions and Answers

Question 1

According to the Sepsis-3 consensus definition, sepsis is best described as:

Accepted Answer

Life-threatening organ dysfunction caused by a dysregulated host response to infection.

Answer

The presence of two or more Systemic Inflammatory Response Syndrome (SIRS) criteria.

Answer

A positive blood culture in a febrile patient.

Answer

Bacteremia leading to hypotension.

Question 2

Which of the following clinical findings is a component of the quick Sequential Organ Failure Assessment (qSOFA) score?

Accepted Answer

Altered mental status

Answer

Heart rate > 100 bpm

Answer

Serum lactate > 2 mmol/L

Answer

White blood cell count > 12,000/mm³

Question 3

The Sepsis-3 definition of septic shock requires persisting hypotension needing vasopressors to maintain a MAP ≥ 65 mm Hg and what other finding?

Accepted Answer

A serum lactate level > 2 mmol/L after fluid resuscitation

Answer

A qSOFA score of 3

Answer

A documented positive blood culture

Answer

Acute kidney injury with oliguria

Question 4

A physician documents 'sepsis due to pneumonia' and 'acute kidney injury' in separate parts of the record. For coding purposes, what is required to link the AKI to the sepsis?

Accepted Answer

Explicit provider documentation linking the two conditions.

Answer

No further documentation is needed as the link is implied.

Answer

The lab values for creatinine must meet a specific threshold.

Answer

A positive urine culture must be present.

Question 5

A patient is admitted for sepsis. If the source of the infection is known (e.g., pneumonia), how should the diagnoses be sequenced?

Accepted Answer

Sequence the code for sepsis first, followed by the code for the localized infection.

Answer

Sequence the localized infection first, followed by the code for sepsis.

Answer

Only the code for sepsis should be reported.

Answer

It does not matter which code is sequenced first.

Question 6

The term 'urosepsis' is documented in the progress notes. What is the most appropriate action for the CDS?

Accepted Answer

Query the provider to clarify the specific diagnosis (e.g., UTI, sepsis).

Answer

Code for sepsis, as it is clearly documented.

Answer

Code for urinary tract infection, as that is the implied source.

Answer

Ignore the term as it is not a valid diagnosis.